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Service Delivery Innovation Profile

Real-Time Clinical Reminder System Improves Performance on Quality Measures

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Researchers at the University of Michigan Medical School transformed the way services are delivered at their family practice clinics using an electronic clinical reminder and tracking system designed to support evidence-based quality improvement efforts. Staff are able to produce a customized checklist for each patient visit indicating what services are due, document diagnoses and problems, and record actions taken. These changes have improved preventive and chronic disease management scores, in part by empowering staff to take the initiative in providing necessary services before the physician sees the patient.

Evidence Rating (What is this?)

Moderate: The evidence consists of before and after comparisons at five clinical sites that employ approximately 60 clinicians within the University of Michigan's Department of Family Medicine.
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Developing Organizations

University of Michigan, Department of Family Medicine
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Date First Implemented


Problem Addressed

Clinicians often do not track or manage clinical data for their patient populations; and therefore, they miss opportunities to provide evidence-based care (both at the point of care and population-based activities) that have been proven to improve quality and outcomes. For example, studies have found that adults in this country receive only approximately 55 percent of recommended care,1 while studies of specific diseases, such as lung disease and hypertension, and patient populations (e.g., children) have also found a systematic lack of adherence to the provision of evidence-based care.2,3,4
  • Underuse of electronic medical records (EMRs): The many providers who rely on paper medical records often do not know (from a quick review of those records) what preventive or disease management services are due for a patient. A 2006 Commonwealth Fund Survey found that only 28 percent of U.S. primary care physicians use an EMR, a much lower figure than in many other developed nations.5 Even those with EMR systems may find it difficult to provide all necessary services because many systems are poorly adapted to the tasks of providing useful clinical reminders and disease management support.
  • Lack of patient registries to facilitate disease management: Practices often do not maintain accurate registries of all patients with chronic diseases to facilitate the provision of population management activities, such as sending out reminder letters to those with diabetes about the need for annual eye and foot examinations.
  • Inability to provide documentation: Many physicians and physician groups have difficulty providing documentation for the increasing number of pay-for-performance and other incentive/accountability programs that are based on evidence-based quality measures. As a result, these groups may not receive all of the incentive funding to which they are entitled.

What They Did

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Description of the Innovative Activity

Clinician researchers at the University of Michigan created an electronic infrastructure to support evidence-based quality improvement efforts. The system helps staff better prepare for patient visits by producing a customized checklist for each patient visit indicating what services are due, documenting diagnoses and problems, and recording actions taken. This allows nonphysician staff to play a more active role in the provision of routine, evidence-based care, allowing them to work more independently, efficiently, and effectively. Key elements of the activity are as follows:
  • Patient encounter form: Every visit is guided by a customizable patient encounter form that is designed to incorporate a practice's quality goals and measures. It can be printed automatically at patient arrival, manually on demand, or completed using a real-time Web interface. In addition to documenting services due, diagnoses and problems, and actions taken, the system captures elements that do not appear in billing or administrative data such as patient lifestyle characteristics, clinical results such as blood pressure, nonbillable diagnoses such as obesity, and nonbillable treatments such as recommending aspirin for heart disease patients. These elements may be important for quality improvement documentation requirements.
  • Customized recommendations and questionnaires: An important part of each visit are readily available patient recommendations and educational material based on the specific conditions, services, and tests that are relevant to the patient. The system also can generate customized patient questionnaires, such as depression symptom checklists or patient satisfaction surveys, for eligible patients.
  • Reminder and followup support: Staff can take advantage of templates for reminder and followup letters, customized with the patient's information and service needs, that can be mailed to patients. The system also provides a list of patients who need to be called by staff for followup related to chronic disease management, such as needed laboratory tests, screenings, education (e.g., about medication compliance), or followup appointments.
  • Monitoring and analysis of performance for reporting: The system routinely produces performance measurement reports for HEDIS® (Healthcare Effectiveness Data and Information Set), pay-for-performance programs, and other guideline-based measures that are required by external stakeholders. Physicians and staff review the data to identify problem areas that can be acted on to improve performance.

Context of the Innovation

This innovation was developed and implemented at the University of Michigan Department of Family Medicine clinics, which have a staff of more than 300, including approximately 60 physicians. These five clinics serve more than 70,000 patients, of which 15 percent are enrolled in Medicaid and 3 percent are uninsured. The development of the ClinfoTracker system and the associated process changes that accompanied it were motivated by the need for the practice to respond to the growing call for objective quality measurement by pay-for-performance and other public accountability programs.

Did It Work?

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These process changes have substantially increased the delivery of targeted screening, prevention, and disease management services, resulting in improved clinical quality scores.
  • Clinicians pay attention to the reminders: In contrast to the reminder system functions of most EMRs, which are often ignored, providers at these practices respond to more than 85 percent of the clinical reminders as they are salient, timely, and directly tied to measurable performance indicators.
  • Nonphysician staff are more proactive and effective: The system allows nonphysician staff to play a more active role in the provision of routine, evidence-based care, allowing them to work more independently, efficiently, and effectively. For example, system-produced, individual patient reports identified discrepancies between ordered and completed lipid profile tests, allowing an office process problem to be pinpointed and remedied.
  • This leads to substantial improvement: The net result has been meaningful improvement in key measures, including the following:
    • Cancer screening: Sixty eight percent of patients are current on colorectal cancer screening, more than double the rate at baseline.
    • Lead screening: Pediatric lead screening increased from almost zero at baseline to more than 60 percent. The rate tripled in just a few months.
    • Vaccinations: Pneumococcal vaccine administration for adults with indications has reached 70 percent.
    • Diabetes care: Hemoglobin A1c and diabetic nephropathy monitoring exceed 90 percent. Statin therapy, foot examination, and eye examination rates for patients with diabetes exceed 80 percent, higher than national norms.
    • Cardiac care: More than 90 percent of heart failure patients have recent (<3 year) ejection fraction measurements, and more than 80 percent of those with ejection fraction <40 percent are receiving appropriate drug therapy. Ninety percent of patients with coronary heart disease receive antiplatelet and statin therapy, and 68 percent receive beta blockers.
Further evaluation of the impact of the process changes at the practice are in progress.

Evidence Rating (What is this?)

Moderate: The evidence consists of before and after comparisons at five clinical sites that employ approximately 60 clinicians within the University of Michigan's Department of Family Medicine.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Workflow analysis: Before implementation within the clinics, workflow diagrams were developed so that the use of the system and the patient encounter forms in everyday practice could be tailored to the care delivery process in that practice. For example, individual practices were encouraged to experiment and innovate with use of and design of the encounter form (e.g., by incorporating recording of vital signs and reasons for visits directly on the form) to better serve their specific needs and facilitate achievement of their specific improvement goals.
  • Software development: The software was developed using an iterative process of design, testing, and real-world use by the principal inventors, using principles of human factors engineering.
  • Physician and office staff buy-in: Medical directors and office managers were instrumental in achieving buy-in of practice staff.
  • System implementation: The implementation of the modified workflow processes involved a phased rollout to minimize disruptions and introduce it to clinicians, medical assistants, and nurses as it was made a part of each practice's quality improvement process.

Resources Used and Skills Needed

These changes have been accomplished with no change in staffing ratios or patterns, except for the addition of approximately 1.1 data entry full-time equivalents per 100,000 visits.begin fsxml

Funding Sources

American Academy of Family Physicians; Health Resources and Services Administration; National Institutes of Health; Michigan Department of Community Health
Funding has come primarily from internal sources, with additional support provided by the Michigan Department of Community Health, the American Academy of Family Physicians, the National Institutes of Health, and U.S. Health Resources and Service Administration.end fs

Tools and Other Resources

A patient encounter worksheet produced by the system can be found at

Adoption Considerations

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Getting Started with This Innovation

  • Work within existing processes and workflows: The patient encounter form, for example, was adapted by each clinic to fit into their specific workflow and priority areas for improvement.
  • Provide only relevant, actionable information to clinicians: Improvement will not occur without the incorporation of an actionable quality focus at each patient visit and at all levels of a practice. Clinicians do not need to review summary or other information that does not require action at the point of care.

Sustaining This Innovation

  • Monitor performance comprehensively: Track performance in all areas because performance that is strong in one area may be weak in the future and problems that seem unimportant today may be important in the future.
  • Use clinicians to provide input for updates to systems and processes: This step keeps the system useful and meaningful.
  • Avoid using billing information in the system: Standard billing data are not precise or specific enough to support quality-oriented action.

Additional Considerations

  • The most important lesson learned has been the powerful effect that implementing the system has had on practices. The system has led the physicians to come together as a group to decide what care is optimal, what quality goals to pursue, and who should be accountable. It has greatly facilitated the transition to the new model (i.e., patient-centered medical home).

More Information

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Contact the Innovator

Michael S. Klinkman, MD MS
University of Michigan
Department of Family Medicine
Phone: (734) 998-7120
Fax: (734) 998-7335

Innovator Disclosures

Dr. Klinkman has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

Nease DE Jr, Green LA. ClinfoTracker: a generalizable prompting tool for primary care. J Am Board Fam Pract. 2003;16(2):115-23. [PubMed]

University of Michigan Department of Family Medicine—ClinfoTracker [Web site]. Available at:


1 McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-45. [PubMed]
2 Mangione-Smith R, DeCristofaro AH, Setodji CM, et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med. 2007;357(15):1515-23. [PubMed]
3 Mularski RA, Asch SM, Shrank WH, et al. The quality of obstructive lung disease care for adults in the United States as measured by adherence to recommended processes. Chest. 2006;130(6):1844-50. [PubMed]
4 Asch SM, McGlynn EA, Hiatt L, et al. Quality of care for hypertension in the United States. BMC Cardiovasc Disord. 2005;5(1):1. [PubMed]
5 Schoen C, Osborn R, Huynh PT, et al. On the front lines of care: primary care doctors' office systems, experiences, and views in seven countries. Health Aff (Millwood). 2006;25(6):w555-71. Epub: 2006 Nov 2. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: April 14, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 23, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: March 30, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.